Evaluation of Nutrition Care Process documentation in electronic patient records: Need of improvement. Issue 1 (28th July 2014)

• Record Type: Journal Article
• Authors: Lövestam, Elin; Orrevall, Ylva; Koochek, Afsaneh; Karlström, Brita; Andersson, Agneta
• Is Part Of: Nutrition & dietetics. Volume 72:Issue 1(2015:Mar.)
• Page Start: 74
• Page End: 80
• Publication Date: 2014-07-28
• Subjects: Nutrition -- Periodicals; Dietetics -- Periodicals; 613.205
• DOI: 10.1111/1747-0080.12128
• Languages: English
• ISSNs: 1446-6368

Abstract

<abstract abstract-type="main"> <title>Abstract</title> <sec id="ndi12128-sec-0001" sec-type="section"> <title>Aim</title> <p>High‐quality documentation in patient records is essential for patient safety and plays a prominent role in the delivery and evaluation of dietetic/nutrition care. We aimed to evaluate dietitians' documentation in patient records according to the four steps in the Nutrition Care Process: assessment, diagnosis, intervention and monitoring/evaluation.</p> </sec> <sec id="ndi12128-sec-0002" sec-type="section"> <title>Methods</title> <p>A retrospective audit of 147 systematically collected outpatient dietetic notes from primary care centres and hospitals in central Sweden was performed using a validated audit instrument. The instrument was used to assess the documentation of 14 items: 10 items focusing on the Nutrition Care Process steps and four items on language clarity and structure, with a maximum total score of 26 for each dietetic note. The notes were divided into three different quality levels, A (high score), B (medium score) or C (low score). Comparisons were made between notes from primary care and hospitals.</p> </sec> <sec id="ndi12128-sec-0003" sec-type="section"> <title>Results</title> <p>The audit showed that the majority of the notes were placed at level B, scoring 13.5–19.5. Only 3% of the notes scored higher than 19.5. The most frequently documented items were intervention (90%), evaluation (70%) and nutrition problem (56%), whereas the least documented items were nutrition prescription (15%), goal of intervention (9%) and connection of problem‐etiology‐symptom (5%). Flaws in lingual clarity were common (72%). Primary care notes received higher scores than those from hospitals.</p> </sec> <sec id="ndi12128-sec-0004" sec-type="section"> <title>Conclusions</title> <p>The audit shows that Swedish dietetic documentation needs to be improved, for example, by further training and education in the Nutrition Care Process and its standardised terminology.</p> </sec> </abstract>